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118 Cards in this Set

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What characterizes Somatoform Disorders?

- physical symptoms or complaints not fully explained by a medical condition


- the assumption is that there is some psychological explanation for what is happening


- even if someone is presenting physical symptoms, it is classified as psychological because there is not physical explanation for the condition





Why is "somatoform disorder" an umbrella term?

-includes a number of disorders: conversion disorder, somatization disorder, hypochondriasis, body dysmorphic disorder, etc

What do you have to rule out for a somatization disorder?

- an actual medical condition (there are some medical conditions that are very difficult to detect


- effects of a drug


- malingering


- factitious disorder

What is malingering?

Faking the symptoms for some sort of secondary gain. The person doesn't truly have the symptoms, but they describe them to the doctor/psychologist for another purpose.

Factitious Disorder

Someone is presenting these symptoms but there's not obvious secondary gain.



Munchausen Disorder by Proxy

When a parent claims that their child has a lot of these physical symptoms but there's no cause for them.

Conversion Disorder

-symptoms or deficits affecting voluntary, motor, or sensory function that suggest a neurological or other medical condition. But again, there is no medical or neurological condition that is occurring. So the assumption is that there is a psychological cause.


- a lot of times, these conversion disorders are thought to have been brought on by some overwhelming stress. When the stressor is reduced, the conversion disorder miraculously clears up.


- Series of events: Stressor --> conversion disorder --> stress reduces --> after a week or two, disorder disappears

Examples of Conversion Disorder

-Partial Paralysis: paralyzed in a way that psychologically doesn't make sense. Person is really experiencing this phenomenon so it has to be something psychological.


- Pseudo Seizures


-"Hysterical" Blindness: as quickly as it may come on, it can clear very quickly as well; an acute episode of blindness where the cause and resolution is not very clear



Prevalence and Course

-Very rare disorder (~0.005%)


- more common in women

Somatization Disorder

Lots of physical complaints across different systems, including at least:


- four pain symptoms


- two gastrointenstinal symptoms


- one sexual symptom


- one pseudo neurological symptom (like repeated fainting or something along those lines)




Symptoms have to begin early, before age 30. Symptoms have to be persistent for usually at least 6 months of time. Symptoms have to be impairing. Leads to treatment seeking or significant impairment

Prevalence Rates of Somatization Disorder (SD)

- men: <.2%


- women: 0.2-2%


- often comorbid with depression, anxiety, substance abuse, suicidal behavior

Etiology of Somatization Disorder

-found to have a genetic link, runs through families


- heritability or learned behavior: 100-20% of female first-degree relatives of patient also have the disorder



Etiological Models of SD

-body's defense against psych stress; if someone is experiencing a stress beyond this capacity, it seems to be manifested in physical symptoms


- even the slightest amount of pain or discomfort get noticed; sensitivity to physical sensations


-overemphasized fears



Somatization Treatment

- all medical causes are ruled out


- CBT


- Goals of treatment: decrease health care usage and symptom management

Hypochondriasis

- fears or beliefs of having a serious disease based on a misinterpretation of bodily symptoms


-similar to somatization, but symptoms aren’t as wide spread but most likely focused on one thing


-this focus of symptoms makes someone believe they have a specific disorder


-preoccupation persists despite appropriate medical evaluation and reassurance


-usually the symptoms are relatively minor, so it really is a misinterpretation


-has gone on for at least 6 months


-continue to try and get their symptoms checked out because they never believe their doctor

Examples of Hyponchondriasis

-abdominal discomfort: stomach cancer


-minor sores/rashes: skin cancer, lupus, etc

Prevalence and Course of Hypochondriasis

2-7% in general medical practices


-no sex differences


-typical onset in early 20s


-chronic course; tends to persist without treatment


-high anxiety is an associated feature

Etiology of Hypochondriasis

cognitive-behavioral


- really wrapped up in these misinterpretations of symptoms


-dysfunctional thoughts about illness


-symptoms are signs of a serious disease


-need to see a doctor ASAP


-being healthy means being symptom free


-Thoughts lead to: hypersensitivity to symptoms and catastrophizing minor symptoms

Treatment for Hypochondrias

-challenge dysfunctional beliefs, CBT tends to be helpful for that


-inducing minor symptoms to observe effect


-CBT & SSRIs

Changes in DSM 5 for Somatization Disorders

-the dsm 4 disorders of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed. Have been replaced with somatic symptom disorder and illness anxiety disorder


-factitious disorder and conversion disorder are still the same



Somatic Symptom Disorder

-one or more somatic symptoms that are distressing (could have medical cause)


-excessive and disproportionate thoughts, feelings and behaviors regarding those symptoms


-persistent concern — at least 6 months

Illness Anxiety Disorder

-preoccupied with having a serious illness


-somatic symptoms are not present (or very mild)


-high level of anxiety about health;similar to hypochondriasis, but in hypochondriasis there are sometimes symptoms present


-performs excessive health-related behaviors


-illness preoccupation for at least 6 months


-there needs to be some sort of impact on their behavior



Body Dysmorphic Disorder



- preoccupation with some sort of imagined defect in appearance (emphasis on imagined)or


- excessive preoccupation with a slight defect


- causes significant impairment or distress


- moved to obsessive compulsive category in DSM5


- people will focus on the smallest things and blow them way out of proportion


- often leads to suicidal behavior

Associated Behaviors with BDD

-compulsive checking (mirror checking, touching)


-significant efforts to hide imagined defect


-avoidance of normal (often social) activities

Muscle dysmorphia sub-type of BDD

-new to the DSM 5


- feeling like you don’t have as much muscle tone as you might like


-growing sub-group of people who may work out a lot and may actually be objectively quite muscular but they may not feel as if they are muscular enough or that the work they put into it should produce better results


-pre-occupied with it


-compulsive checking



Prevalence and Course of BDD

-approx 1% of general population


-perhaps 6-15% of plastic surgery population


-onset usually in adolescents


-no sex differences


-chronic condition, but with age it tends to get a little bit better



Treatment of BDD

plastic surgery (ineffective)




cognitive-behavioral therapy (small scale evidence suggesting that they’re helpful, but not many studies)


-similar to the CBT you get for OCD


- cognitive therapy looking at the dysfunctional beliefs that people have


-look at the beliefs that maintain this disorder as well




SSRI’s (same as CBT)




Beever’s hunch is that these treatments are mildly affective because of their chronic course

What is dissociation

-the minds ability to engage in activities outside of conscious awareness




examples:


- driving a very familiar route and you may find yourself half way home without realizing how you got there


-daydreaming


- missing parts of convos


- automatic behaviors

Dissociative Disorders

- involve disruption or alteration in consciousness, memory, or identity


-there may be times where a certain identity is not in control of your behavior (another identity, an alter-identity takes control)

Dissociative Identity Disorder

-formerly known as multiple personality disorder


- presence of two or more distinct identities or personality states (“alters”)


-at least two of the identities recurrently take control of the person’s behavior


-an inability to recall important personal info that is too extensive to be explained by ordinary forgetfulness


-there are in essence these distinct identities that take over a person’s behavior from time to time



DID History

-Many cases: 1880-1920


-Almost no cases - 1920-1970


-Sharp increase in cases since the publication of “sybil” in 1973 (highly publicized case of DID and since then, there had been a significant increase in the prevalence of DID)


- early cases reported an average of 2 alters. Modern studies report an avg 13-16 alters with as many as 100 in some cases



How can alters differ from "core" personality and other alters? (according to research)

- word fluency/education

- handwriting


- visual acuity


- sensitivity to allergens


- response of blood glucose to insulin


- fMRI patterns



Traumagenic View/Etiology of DID

-childhood trauma “fractures” the personality


-child defends against trauma by dissociating


-they are basically saying “no that trauma didn’t happen to me, it happened to someone else” and it’s their way of coping


-almost everyone who has this disorder has experienced some sort of childhood trauma


-had they not developed the multiple personalities, they may have suffered from PTSD


-“locus of control shift”: taking control the abuse by fracturing their personality


- clinically, this makes a little sense; almost everyone with DID has experienced a trauma!

Sociocognitive Views

-Iatrogenic


-many or most DID patients are highly suggestible


-therapists and others can create false memories or reinforce the disorder


-like in the video, the therapist will ask “let me hear from this personality, let me hear this personality, now let me hear this personality”


-therapists used to ask “is there another side to you? Is there a piece I’m missing here”; this was an attempt to understand what the person was going through but it may have been reinforcing or even creating these personalities


-one of the few disorders that tends to get worse after it’s diagnosed and after they’ve been in treatment for awhile


-inadvertently creating the problem rather than helping


-sometimes, the patient feels this incredible force of demands as well as the therapist asks her questions; “I can’t just avoid the question, and I guess I can see myself as having another aspect or identity to myself”


-so the patients feel they need to please their therapists and go along with what they are saying, and the therapists thinks they’ve finally made a break through and latches on to the new identity, forcing them to explore it more.

Sybil Exposed

-Sybil was a well known case of DID and the story was published in 1973


-a new book called Sybil Exposed just came out that argues that the entire disorder didn’t unfold on its own


-Sybil (whose name was actually Shirley) was a girl who needed a lot of emotional support and attention and became very attached to her psychiatrist


-because she felt like she wasn’t getting enough attention from her psychiatrist, she came into the office one day and pretended to be someone else; She created this personality called Peggy who was this little girl


-Dr. Wilber thought that this was a new interesting case that she could work on and began giving Shirley a lot of attention; in many different sessions Shirley was able to give Dr. Wilber what she wanted and gave her all sorts of different personalities that weren’t real manifestations of DID



How did lilienfeld describe DID?

-“we are hard-pressed to identify another DSM-IV disorder whose essential feature (multiple identity enactment) (a) is often or usually unobservable prior to treatment and (b) tends to emerge and become considerably more florid during treatment”


-treatment is often ineffective


-labeling a patient as DID may, in itself, suggest a poorer outcome

Dissociative Fugue

-sudden unexpected travel away from home or one’s customary place of work with an inability to recall one’s past


-confusion about personal identity or assumption of a new identity


-unlike DID, they simply don’t remember who they once were and develop a new identity based on who they think they are

Example of Dissociative Fugue

-in the news, you hear occasionally about someone from Austin who was found in Seattle and is now working in a different profession and having taken on a new identity, but reunite with their family


-even after reuniting with their family, however, they still may not completely remember their family or identity

Associated Features of Dissociative Fugue

semantic and procedural memory intact


-the ability to perform skills


-their memory doesn’t completely go away, but it’s just memory for certain aspects of their life (memory of who they are, their family, etc)




Very rare




defense against overwhelming stress

Dissociative Amnesia

inability to recall important personal info that cannot be explained by ordinary forgetfulness




Associated Features


-Episodic/autobiographical memory impaired (e.g. what happened during a traumatic event)


-Loss is (usually) reversible


-procedural and semantic memory intact


-lasts from days to weeks (rarely, years)

Personality Disorders - What is a personality and What is a PD?

- personalities make up our character, distinguish who we are, and make us different from others


- how we see the world, who we are as people, etc


- personality disorders make it more difficult to function effectively in the world because of a defect or abnormality in their personality

General Personality Disorder

an enduring pattern of inner experience and behavior that deviates from expectations of the individual’s culture. Manifests in two or more areas:


-cognition (ways of perceiving self/others)


-affectivity (range, intensity, lability)


- interpersonal functioning


-impulse control




You can describe their behavior in a few different ways


- enduring pattern is inflexible and pervasive; generally act in a similar fashion regardless of the context of the env they are in


-personality traits lead to distress or impairment in social, occupational, or other areas of functioning


-stable, onset in adolescence/early adulthood


-not consequence of another mental disorder


-not consequence of drugs or a med condition

What are the different Personality Disorder clusters?

A: odd/eccentric


-paranoid


-schizoid


-schizotypal




B: dramatic/erratic


-Borderline


-Histrionic


-Narcissistic


-Anti-social




C: Anxious/Fearful


-avoidant


-dependent


-obsessive-compulsive

Paranoid PD

- chronic suspiciousness/mistrust; they don’t trust people and because of that they are always on guard and always looking for threats in their environment


-vigilant for cues of being mistreated; always think people are out the get them or take advantage of them, so they are always looking out for signs of that


-misread innocuous signals


-do not accept blame and are very defensive; they don’t accept blame very well because they are always on the look out for other people trying to make them look bad


-they will go on the counter-attack pretty easily; if they perceive these threats, they will get angry very quickly and you can say something fairly innocuous and a Paranoid PD will lash out very quickly. Easily triggered anger.

Causes of Paranoid PD

links with schizophrenia


-very soft delusional paranoia in this personality disorder that MIGHT link it with schizophrenia; but no bizarre delusions that you see in schizophrenia


-similar link with other Cluster A PDs







Treatment for Paranoid PD

No effective treatments


- difficult to engage Paranoid PD Patients in treatment because they are very unwilling to trust the therapist and treatment provider because of the nature of their personality


-they won’t engage in the process because they are chronically suspicious, thinking maybe the other person has another angle


-don’t like being vulnerable in treatments or at all, but treatments often require the patient to be vulnerable so it makes the process difficult

Schizoid PD

Characteristics


- no desire for close relationships


- don’t enjoy close relationships


- no empathy (the ability to understand and share the feelings of another)


- don’t really respond to other people’s praise or criticism (generally indifferent to other people, including their praise/criticism)


- tend to not have strong interests or tend to not be passionate about various things




Common jobs include anything with very little interaction


- midnight shifts at places where very little people come through, like maybe midnight at supermarket, security guard, etc




some people criticize that this is a “disorder” since these people don’t really suffer or have impairments


- usually it’s the families that feel like it’s a problem or an issue, but people with this PD don’t really mind because they prefer it this way


- however, their lack of interest in relationships and no empathy is a bit impairing even if they don’t see it that way



Treatment for Schizoid

-emphasize social skill training


-taught to feel empathy


- role playing where therapist takes on role of friend


-identify social network

Schizotypal PD

Characteristics


- ‘Mild’ schizophrenia-spectrum symptoms


-odd beliefs


-eccentric speech


-eccentric behavior and appearance


-social anxiety: people may feel like they have trouble getting along with others or as if they are being rejected by others because they don’t understand them, and therefore these people feel they need distance themselves from everyone else




May be able to have relationships and hold a job but they probably won’t be long lasting because some of the behaviors and beliefs may interrupt full functioning




Schizotypal personality correlates with early adversity, such as a history of childhood sexual abuse


- however associations not specific to schizotypal personality disorder



Treatment Schizotypal PD

- there is almost no treatment data for this disorder


- if anything they are most likely treated with anti-psychotics


-but they don’t often find themselves in treatment


- do experience some stress, particularly around other people, so they’ll seek treatment more than some of the other disorders



Causes of Schizotypal PD

- if you have schizophrenia in your family, you may also be at risk for schizotypal disorder




- appears to be inheritable and the two disorders run in the same genre

Avoidant PD

Characteristics


- really fearful of criticism, rejection, disapproval, embarrassment


-as a result, they are reluctant to enter into relationships and avoid people. Different from schizoid PD because in schizoid people have no desire to be in relationships. In avoidant pd, people WANT to be in relationships and with people, but they are afraid to.


- restrained, withdrawn


- feelings of low self-worth, incompetence


-reluctance to take risks





Causes of Avoidant PD

-parenting may contribute to the dev of APD


-more likely to report childhood experiences of isolation, rejection, conflict with others, and parents as more rejecting, guilt engendering, and less affectionate

Treatment of Avoidant PD

-Behavioral intervention techniques for anxiety and social skills problems have had some success


-resembles social phobia, so same treatments used for both


-Therapeutic alliance—the collaborative connection between therapist and client—appears to be an important predictor for treatment success in this group


- More easily treated to see improvements

OCPD (Obsessive Compulsive Personality Disorder)

Characteristics


- perfectionism (that interferes with productivity)


-preoccupied with details, rules, schedules; can’t delegate tasks to other people because they would rather do it themselves


- work rather than pleasure oriented


- stubborn, rigid, “control freak”; their way is the correct way, don’t trust others because they won’t do it correctly


-inflexible; hard to work with these people


-tend to not be as fun or interested in fun activities


-the sorts of personalities where they say “Well, it’s 11:00 PM so it’s time for me to go."




Don't confuse with OCD!


- not an obsession, compulsive disorder


- just very preoccupied with getting everything right and perfect

Treatment and Etiology of OCPD

-very little research on the etiology and treatment of OCPD


-therapy often focuses on fears that underlie need for order


-therapists help you relax or use distraction techniques to redirect compulsive thoughts (form of CBT); seems to be effective

Dependent PD

Characteristics


-rely on others to make ordinary decisions as well as important ones —> results in an unreasonable fear of abandonment


-sometimes agree with other people when their own opinion differs so as not to be rejected


- desire to obtain and maintain supportive and nurturant relationships which may lead to other behavioral characteristics (submissiveness, timidity, and passivity)


-feelings of inadequacy, sensitivity to criticism, need for assurance (similar to APD above); but APD responds by avoiding relationships; DPD responds by clinging to relationships

Causes and Treatment of Dependent PD

- such disruptions as the early death of a parent or neglect or rejection by caregivers may cause people to grow up fearing abandonment


- If early bonding is interrupted, individuals may be constantly anxious that they will lose people close to them.


-appear to be ideal patients because of their attentiveness and eagerness to give responsibility for problems to therapist but submissiveness negates major goal of therapy: make the person more independent and personally responsible


- therapy must progress gradually —> patient develops confidence in indecent decision making

Antisocial PD

characteristics


- persistent disregard in violation of the rights of others; essentially not worried about the rights of others and looking out for yourself, obtaining what YOU want in disregard for others


- conduct disorder before age 15; frequent lying, frequent stealing


- no regard for the truth, no remorse


-no empathy; not having a lot of concern for other people


- failure to plan ahead; very impulsive, when they see something they wan’t to do they just do it without planning


- breaking laws


-irritable and aggressive


-inconsistent work and relationships history

Psychopathy and APD

-psychopathy is having no regard for other people, low empathy, etc


- psychopaths may not all meet the other criteria for APD but virtually all people with APD are considered psychopaths


- think of it as someone who is really depressed but doesn’t meet the criteria for MDD. Same with psychopaths who don’t meet criteria for APD.

Statistics for APD

- more common among men than women


- 12 month prevalence: 1% of US adult population (from separate website)

Etiology of APD

study looked at orbital frontal functioning (OFC) in APD


- found reduced orbital frontal function among psychopaths


- OFC has been shown to be involved in ethical behavior, moral decision making, and impulsive control, all things which APD is involved with


-people with low activity in the orbital cortex could be psychopaths/APD




Fallon-Neuroscientists Radio Snippet


-research on Orbital Cortex and psychopaths/murderers


-possible that it is passed down through family?


-brain patterns and genetic make up aren’t enough to make a psychopath however.


-You also need a history of childhood abuse.


-so childhood could make all the difference in whether a person turns out to be a psychopath or not

Genetics in APD

- heritability estimated 40-50%


- higher in children if parents had either APD or substance abuse


- genes increase vulnerability for impulsivity, lack of fear, aggressiveness, etc., but environment may influence how they manifest


- these genes could be useful in certain occupations or activities: aggression is rewarded in sports or the lack of fear is helpful in firefighters and police officers


- so it’s possible under the right circumstances that these traits can lead to very admiral outcomes. but if you take individuals who have the same abilities but had adverse circumstances growing up and an abusive environment, they may grow up to develop psychopathy or APD. the environment can shape where the vulnerability goes





Childhood Maltreatment in APD

-early adversity is a risk factor


-antisocial parent + adverse home life = high risk for APD: adopted offspring of APD mothers more likely to develop APD if left in orphanages


- childhood maltreatment + MAOA gene (aka warrior gene) = APD

Emotional Deficits in APD

- lack of response to punishment


- lack of stress response predicts future conviction of crime; in one study, the kids were about 13 yrs old


- difficulty identifying emotions of others; people high in psychopathy have more difficulty identifying when people are experiencing sadness, fear, etc

Therapy for APD

- it is virtually impossible to achieve collaboration with an antisocial patient in ordinary dyadic therapy




Clinical wisdom


- avoid any power struggles and confrontational stance (“i’m right, you’re wrong”)


- Team approach, with built-in therapist support


- self-assured, relaxed, non-defensive therapist style


- focus on self-defeating nature of antisocial behavior; “How has this affected you so far? How are you benefiting? What can we do so that you don’t end up back in prison?"


- do not expect genuine collaboration or connection in treatment




-The focus for treatment is really on changing the person's behavior in treatment, so they don't end up back in prison

Borderline PD

Characteristics


- impulsive and unpredictable


-self harm/self mutilation - sometimes referred to as parasuicidal because the intent is not to kill themselves but rather because of one of the two reasons: they feel very overwhelmed by their emotions and so they numb their emotional state by harming themselves or it’s a way of drawing people back in because their social relationships tend to be fairly unstable


- unstable moods and relationships: fluctuate from intense anxiety to intense anger or irritability and relatively minor events may lead to extreme responses


-fluctuating idealization and contempt


-anger outbursts


- identity confusion: have some empty feelings inside where they don’t really know who they are or have a good sense of what they value.


- May define themselves based on their relationships to a degree


- frantic efforts to avoid rejection (including self-harm)


-intense anger and contempt shows up when they feel like they have been rejected


-transient psychotic episodes

Dialectical Behavior Therapy

- treatment of choice for BPD


- complex, multifaceted treatment for BPD that ideally includes group and individual interventions and extensive therapist support


-first goal is to foster commitment to treatment and reduction of self-harm/suicidality


-what they will have patients do when they start treatment is sign a document (not binding) that is a contract with the therapist that says over the course of a year I agree not to harm myself. When I feel overwhelmed, I will engage in the following behaviors


-this is more of a symbolic gesture if anything; indicating the patient’s willingness to engage in treatment and commit to reducing self harm


-in most people who practice DBT, if someone is not willing to agree with the contract then you can discuss that it might not be time to start this treatment


- treatment for which there is the greatest evidence


-synthesis or merging of trying to change something while also accepting that it is what it is; that's why it's called dialectical behavior therapy

Components of DBT

-processing traumatic events/PTSD


-self-care


-radical acceptance


-interpersonal effectiveness


-distress tolerance


-emotion regulation


- mindfulness

Interpersonal Effectiveness (DBT)

- how to get along with others more effectively


- helping clients get their needs met (make requests and say no) in a way respectful to both self and others


- being aware of reactions to others as well as what goals are


- assertive but not aggressive

Distress Tolerance (DBT)

- skills to help get through a crisis situation without making matters worse


- not intended to help clients feel better, because you acknowledge there is distress in the moment; but instead you’re allowing them to tolerate the anxiety and not take action based on the distress/anxiety


- learning how to cope with the distress without cutting yourself or making matters worse


- anything can help tolerate the moment: imagery (relaxing/safe place), prayer or meditation, relaxation exercises, reminding yourself to just do one thing at a time, take time out of the situation

Emotion Regulation (DBT)

- change our reaction to our emotions


- NOT changing/controlling emotions


- Learn to identify and use emotions as allies not enemies; emotions are useful so we can use the info from emotions to our benefit as long as we don’t over respond to them


- mindfulness: very skilled at distancing from emotions, must slow down and practice this skill

Mindfulness

- becoming aware of and present with our thoughts and emotions


- differentiating ourselves from our thoughts and emotions - getting unfused because our emotions are not who we are


- practicing controlling our attention


- “mindfully” eating — eating raisins one at a time and really experience what each raisin is like


- NEVER about controlling our thoughts — underlies every single aspect of DBT

Meta analysis study comparing DBT efficacy

- fairly strong advantage of DBT over treatment as usual


- a medium effect; not a large, whopping effect but certainly noticeable and clinically significant effect for DBT helping Borderline PD


- particularly good at reducing the number of re-hospitilizations people experience; reduces the revolving door of someone harming themselves, going to the hospital, coming out and harming themselves again, etc

Histrionic PD

- tend to be overly dramatic and often seem to be acting


- histrionic: theatrical in manner


- inclined to express their emotions in an exaggerated fashion


- tend to be vain, self-centered, and uncomfortable when they are not in the limelight


- seductive in appearance and behavior, typically concerned about looks


- seek reassurance and approval constantly and may become upset/angry when others do not attend to them or praise them


- tend to be impulsive and have great diff delaying gratification


- impressionistic cognitive style: tendency to view situations in global, black and white terms


- speech is often vague, exaggerated, and lacking in detail


- higher in women than men; could be due to bias since the characteristics are associated with the stereotypical western female

Causes of Histrionic PD

- possible relationship with antisocial PD; evidence suggests they co-occur more often than chance would account for; may be sex-typed alternative expressions of the same unidentified underlying condition, where men are predisposed to APD while women are predisposed to HPD


- some say it should be reclassified in DSM5 to be included under another PD since there is overlap between HPD and other personality disorders (like borderline, narcissistic, and dependent pds)

Treatment of Histrionic PD

-some therapists have tried to modify the attention-getting behavior; study ex: rewarded for appropriate interactions and fined for attention-getting behavior


- large part of therapy focuses on the problematic interpersonal relationships bc they often manipulate others through emotional crises, using charm, sex, seductiveness, or complaining


- need to be shown how the short-term gains derived from this interactional style result in long term costs


- also need to be taught more appropriate ways of negotiating their wants/needs

Narcissistic PD

- extreme tendency to think highly of yourself, exaggerating real abilities, and considering yourself as diff from others and deserving of special treatment


- psychoanalysts used the term to describe ppl who show exaggerated sense of self-importance and are preoccupied with receiving attention


- unreasonable sense of self-importance


- lack sensitive and compassion for other ppl bc they are preoccupied with themselves


- uncomfortable unless someone is admiring them


- grandiosity: exaggerated feelings and fantasies of greatness


- require and expect a great deal of special attention


- exploit others for their own interests


- show little empathy


- envious/arrogant in front of other successful ppl


- depressed when they often fail to live up to their own expectations

Causes and Treatment of Narcissistic PD

- may arise largely from a profound failure by parents of modeling empathy early in a child’s development; child remains fixated at a self-centered, grandiose stage of development


- involved in a fruitless search for the ideal person who will meet her unfulfilled empathic needs


- prevalence in most Western societies, primarily as a consequence of large-scale social changes, including greater emphasis on short-term hedonism, individualism, competitiveness, and success.


- “me generation"


- when therapy is attempted, it often focuses on their grandiosity, their hypersensitivity to evaluation, and their lack of empathy toward others


- cognitive therapy to replace fantasies with a focus on the day-to-day pleasurable experiences that are attainable


- relaxation training (coping strategy) used to help face/accept criticism


- learn to focus on others’ feelings


- treatment often initiated for depression, which is a vulnerability for this disorder (in middle age esp)

Sexual Response Cycle

- important because sexual dysfunctions can occur at any of the stages of the cycle


- desire, arousal, plateau, orgasm, resolution

Plethysmography

Penile Plethysmography


- the main way of measuring arousal is with this piece of equipment


- basically just measures blood flow to the penis


- larger circumference and more blood flow is thought to suggest more arousal




Vaginal Plethysmography


- use photo plethysmography


-insert the equipment into the vagina and there is a led light source and photo receptor


- the more arousal the woman is experiencing, the change of blood flow occurs which reflects more light that is picked up by the photo receptor


- greater reflective light = greater blood flow = greater arousal

Role of anxiety in Sexual Arousal/Performance

- a lot of models thought that sexual dysfunction was due to great anxiety; now shown to be quite the opposite




the current thinking about this is that it may not be so much because of anxiety but these diff come from what you attend to during the sexual response cycle


- for individuals who have dysfunctional performance, there is some sort of request or expectation for performance. They engage in sex and they might experience some neg affect/anxiety, but it’s not the anxiety that interferes with the performance


- what they begin to think about is the PUBLIC consequences of not performing; “oh this is so embarrassing, this is happening again, my partner is going to be embarrassed, etc”


- rather than focusing on the erotic cues, the focus is on the implications of what can go wrong, which decreases autonomic arousal which then feeds into more cognition of things not going well and more consequences of not doing well and ultimately leading to dysfunctional performance and even avoiding sexual acts (maybe now is not the right time)


- in contrast with individuals in the functional performance loop; the idea of having sex leads to positive affect and focusing on erotic cues/sexual experiences which facilitates arousal which then facilitates focus on erotic cues and then leads to functional performance



Study on Anxiety and Arousal

- young, sexually functional men watched erotic film- some were just told to watch


- some were told 60% chance of shock on the arm regardless of arousal (non contingent)


- some were told 60% chance of shock if they did not achieve avg level of erection (contingent on lvl of erection); this was meant to create performance anxiety


- what they were expecting was that the last condition was the condition where you would see the lowest level of arousal


- they actually found the opposite


- the conditions where there was contingent shock or non contingent shock led to about the same level of arousal and both were higher than the no shock group


- therefore, the presence of anxiety helped with arousal- replicated study on women as well to study anxiety and arousal


- seems like anxiety doesn’t impair performance but if anything facilitates it

Summary of Treatment for Sexual Dysfunction (from text book)

- availability of drugs for male erectile dysfunction is widespread


- Psychological treatment of sexual arousal disorders requires further improvement, and treatments for low sexual desire are largely untested.


- most new medical developments are frequently appearing but still intrusive and clumsy


- most health professionals tend to ignore the issue of sexuality in older adults.


- Along with the usual emphasis on communication, education, and sensate focus, appropriate lubricants for women and a discussion of methods to maximize the erectile response in men should be a part of any sexual counseling for older couples. Continued sex is important for these couples, even if it isn't always intercourse


-the overwhelming consensus is that a combination of psychological and drug treatment, when indicated, will continue to be the treatment strategy of choice.



Causes and Treatment of Sexual Dysfunction (from text book)

-Sexual dysfunction is associated with socially transmitted negative attitudes about sex, current relationship difficulties, and anxiety focused on sexual activity.


- Psychosocial treatment of sexual dysfunctions is generally successful but not readily available. In recent years, various medical approaches have become available, including the drug Viagra. These treatments focus mostly on male erectile dys- function and are promising.

Best ways for professions to assess Sexual Behavior

-Interviews, usually supported by numerous questionnaires because patients may provide more information on paper than in a verbal interview
- A thorough medical evaluation, to rule out the variety of medical conditions that can contribute to sexual problems


- A psychophysiological assessment, to directly measure the physiological aspects of sexual arousal

Gender Identity Disorder

- strong and persistent gross-gender identification


- gender dysphoria (persistent discomfort about one’s biological sex)


-causes a lot of distress


- occurs in males and females


- typically sexually attracted to same sex, but resent being labelled gay because they believe they were born in the wrong biological sex


-the only effective treatment: surgical sex reassignment (psychotherapy usually not effective)


- the psychotherapy was used to convince them otherwise; thought that they needed to change the fundamental belief that they were born the wrong sex


- having psychotherapy in the context of the surgical sex reassignment is really important however because it helps with support and give them a realistic view of what life will be like after the surgery. not all their issues will be solved, and so psychotherapy will be helpful. psychotherapy in this case is not designed to convince them to not go forward with surgery



Gender Identity Disorder - transition details/statistics

- 75% report satisfaction with new identity


- adjustment is better for female-to-male ; might be because it’s harder to change the features of the male identity


- male to female cannot bear children, can have prostrate cancer, and other “male” problems


- can have successful intimate relationships: can have orgasms following surgery



Causes of GID

- genetics play a role: 60-70% of the explanation may be due to genetics




exposure to higher levels of testosterone or estrogen in utero?


- androgen controls the development and maintenance of male characteristics in vertebrates by binding to androgen receptors.


- lower ratios of the index/ring finger ratio suggests higher androgen exposure - fourth finger is longer in these people




gender non-conforming behavior in childhood?


- turns out there is a pretty loose association there (more associated with homosexuality, but even that is a stretch)


- also no association if the child plays with both same-sex and cross-sex toys


- playing with the toys isn’t so much a causal factor but rather a symptom of GID if it is related at all




Causes still largely a mystery

Paraphilia

- sexual arousal/attraction focused on inappropriate people/objects


- disorder if distressing/impairing/harms others




includes


- frotteurism


- fetishism


- sexual sadism and masochism


- voyeurism


- exhibitionism


- transvestic fetishism


- pedophilia


- incest



Frotteurism

men with this arousal pattern rub against women until they are stimulated enough to the point of ejaculation

Fetishism

- arousal from inanimate or tactile (rubber) objects


- sometimes includes specific body parts, called partialism


- nonliving objects needed for sexual arousal


- could include underwear, shoes, balloons...

Sexual Sadism and Masochism

- sadism: arousal from causing harm/humiliation to others


- masochism: arousal from receiving harm/humiliation


- Sadistic Rape: Rapists are aroused during both descriptions of consensual and nonconsensual sex. Among the rapists they were evaluating, a subgroup seemed to be particularly aroused when force and acts of cruelty were involved. To assess this reaction more completely, they put to- gether a third audiotape consisting of aggression and assault without any sexual content. A number of individuals displayed strong sexual arousal to nonsexual aggressive themes, as well as to rape, and little or no arousal to mutually enjoyable intercourse. These were the sadistic rapists.

Voyeurism

- peeping tom; arousal from seeing others undressed


- anxiety of being caught produces more arousal


- prevalence of 7.7% from at least one incident

Exhibitionism

- arousal from exposing yourself to others


- exhibitionism is often associated with lower levels of education, but not always.


- thrilling element of risk is important


- prevalence of 31% who reported at least one instance of exhibitionismthe behavior must occur repeatedly and be compulsive or out of control

Transvestic Fetishism

- sexual arousal is strongly associated with the act of dressing in clothes of the opposite sex, or cross-dressing


- It is not unusual for males who are strongly inclined to dress in female clothes to compensate by associating with so- called macho organizations


- 2.8% of men and 0.4% of women re- ported at least one episode of transvestic fetishism


- wives of many men who cross-dress have accepted their husbands’ behavior and can be quite supportive if it is a private matter between them


- 60% of more than 1,000 men with transvestic fetish- ism were married at the time of the survey

Pedophilia and Incest

Pedophilia: arousal from children/underage


Incest: arousal/sexual acts with family members

Hypothetical Model of Paraphilia

- Early inappropriate sexual associations or experiences (some accidental and some vicarious), which leads to either...


- possible inadequate development of consensual adult arousal patterns and/or possible inadequate dev of appropriate social skills for relating to adults, which both can lead to...


-inappropriate sexual fantasies repeatedly associated with masturbatory activities and strongly reinforced, which leads to...


- repeated attempts to inhibit undesired arousal and behavior resulting in (paradoxical) increase in paraphillia thoughts, fantasies, and behavior, which then leads to...


- paraphilia

Developmental Psychopathalogy

- the macroparadigm: doesn’t adhere to one theoretical paradigm or model of psychology. Integrated model


- developmental + clinical psychology/psychiatry


- central proposition: problem behavior can only be understood when normal development is considered


-provides an integrative or multi-theoretical framework for understanding abnormal behavior


-empirically-based

History of Autism

Leo Kanner (1943)


-early infantile autism


-“cold rejecting mother” or “refrigerator parent"


-first to use the term autism




Hans Asperger (1944)




Both researchers were describing children in a similar fashion


- they weren’t collaborating because it was during the cold war


- when both researchers described it, they came to the conclusion that it was a biologically derived disorder


-leo kanner’s students then put together the theory of a cold rejecting mother causes autism; however, there hasn’t been any evidence for this




Awareness and knowledge of autism has expanded greatly within the past 15 years

Symptoms of Autism

persistent deficits in social communication


- quantitative impairments in social communication


- incredible variability in people who carry the same diagnosis


- at the very severe end of the spectrum, we could be seeing a child who haven’t developed language and never will


- at the very mild end of the spectrum, you have children who are just slower to develop language but once they get to school their vocabulary is developed and they can use their language normally. But the way they use their language socially is abnormal


- example: child #1 says a bug flew into his mouth and he wanted to puke. Child with autism: says a bug flew into his mouth and it made my stomach sad. nothing wrong with the statement, it makes sense grammatically and in its language but the fact that he said it made his stomach feel an emotion is strange


- example: saying “swiper no swiping” from Dora instead of “Hey, give that back” when something is stolen from them.




persistent deficits in social interaction


- at the more severe end: kids who just don’t have friends and don’t appear remotely aware of the social world around them; left to their own


- at the more mild end: people who are incredibly socially engaged, craved social interaction, and love they friends; however, they struggle making age appropriate friendships




restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two symptoms


- at the more severe end: repetitive motor behaviors, with the most common being rocking, hand flapping, wiggling, toe walking, examining things in an unusual way (looking at things from the side of your eyes)


- at the milder side: unusual interests in activities, can be unusual in the contact or unusual in the way that they are interested in it; example: interested in spinning things like water going down the toilet, trains, knowing everything about maps


- the feature that is there for both types is intense preoccupation




Onset prior to age 3


Need 6 or more symptoms in the three domains listed above

Joint Attention

- the function of joint attention is to share interest in an object or event


- joint attention is demonstrated by the coordination of attention around an object or event through eye contact, pointing, or showing. this is how you can tell if babies who don’t have verbal abilities have joint attention


- joint attention emerges at 6 months and is well developed by 18 months


- as humans, we are hard wired to share our experiences with other humans


- joint attention is not apparent in kids with Autism, and this is unique to Autism only


- some autistic kids will use eye contact to use it as a request (to get something, to get someone to stop something, etc). This is different from eye contact in joint attention.

Examples of Joint Attention

- typically-developing toddlers: get very excited when they see a new toy; the baby looks at the dancing penguin, gets happy, looks up at the experimenter to show his happiness, and even further imitates the penguin to display what he likes about it


- young child with down syndrome: lots and lots of joint attention


- young child with autism: no joint attention at all, even though he has interest in the toy and winds it up

DSM-IV Pervasive Dev Disorders

Autistic Disorder




Retts Disorder


- much more severe


- much more pervasive


- shortened life span




Childhood Disintegrative Disorder


- much more severe


-much more pervasive


-shortened life span




Aspergers Disorder




Pervasive Dev Disorders, NOS

DSM-IV Asperger's Disorder

- same criteria as autism, except:


- no clinically significant delay in language (e.g., words by age 2, phrases by age 3)


-No clinically significant delay in cognitive development or in the development of age appropriate self-help skills, adaptive behavior, and curiosity about the environment


- tend to be higher functioning


-if you put a high functioning autistic 5 yr old next to a 5 yr old aspergers’s child, you may not be able to tell the difference without asking parent when they started talking

DSM-IV PDD, NOS

- severe and pervasive impairment in the development of reciprocal social interaction associated with impairment in verbal or nonverbal communication or with the presence of stereotyped behavior, interests and activities, but the criteria are not met for a specific pervasive developmental disorder


- aka: atypical autism


- on the autism spectrum but do not fully meet autism criteria

Changes in DSM-V for Autism and other disorders

- Removed: Retts Disorder C and Child Disintegrative Disorder




- Collapse remaining: Autism Spectrum Disorder




- Age of onset extended in early childhood




- Introduce: social (pragmatic) communication disorder



DSM-V Autism Spectrum Disorder

persistent deficits in social comm and social interaction across multiple contests, as manifested by the following, currently or by history


- deficits in social-emotional reciprocity


- deficits in nonverbal communicative behavior


- deficits in developing, maintaining, and understanding relationships




Restricted, Repetitive patterns of behavior, interests, or activities, as manifested by at least two symptoms




symptoms must be present in the early dev period but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life




symptoms cause clinically significant impairment in functioning




these disturbances are not better explained by intellectual disability or global dev delay




*** severity is based on social comm impairments and restricted, repetitive patterns of behavior

DSM-V Social (Pragmatic) Communication Disorder

persistent difficulties in the social use of verbal and nonverbal comm as manifested by


- Deficits in using comm for social purposes


- impairment in the ability to change communication to match context or the needs of a listener


- difficulties following rules for conversation and storytelling


- difficulties understanding what is not explicitly states and nonliteral or ambiguous meanings of language




the deficits result in functional limitations




symptom onset is in the early dev period




the symptoms not attributed to another condition




probably have great joint attention though

The Autism Controversy

- Redefining autism: in a prelim analysis, three researchers estimate that far fewer people with autism or a related disorder would meet the criteria for autism spectrum disorder after a change proposed for the 5th edition of DSM


- there is no difference between autism and Aspergers in regards to the brain, reaction to treatment, developmental progression, etc


- they are given names but there aren’t huge differences


- if you have Aspergers, however, you have access to less services and treatments. Even if you have the same IQ, developmental age, etc as someone with autism


- the biggest concern was that in changing the criteria from DSM-IV to DSM-V was that lots of kids with Aspergers or PDD-NOS, or autism would fall off the spectrum. Some kids who qualified under DSM-IV would no longer qualify under DSM-V. Those with Aspergers and PDD-NOS fell off the most


- 76% of classic autism defined in DSM4 would qualify under DSM 5


-24% of Aspergers would qualify under DSM 5


-16% of PDD-NOS would qualify under DSM 5

The Reality (Study)

- 4,453 children with clinical DSM4 PDD and 690 children with other diagnoses


- gold standard tools (ADI & ADOS) were used to evaluate the sensitivity and specificity of DSM-IV and DSM-IV criteria when compared with clinical diagnoses




based on ADI only:


-DSM-V sensitivity ranged from .89-.93


-DSM-5 specificity was .52 overall (DSM4 ranged from ,24 (PDD, NOS) to .52 (autistic disorder




Based on ADI and/or ADOS


-DSM-5 sensitivity ranged from .97-.99


-DSM-5 specificity increased to .63




Conclusions


- sensitivity: most children with DSM 4 PDD diagnoses will remain eligible for an ASD diagnoses under DSM5


-specificity: the DSM 5 ASD criteria have greater specificity compared to DSM 4 aspirer’s disorder and PDD< NOS., especially in cases where both parent and clinician identify abnormal behavior

ASD Prevalence

- 1 in 68 children


- 1 in 42 boys


- 1 in 189 girls


- 1% of gen population




Why are prevalence rates increases?


- changes in diagnostic criteria and assessment


-inaccurate diagnoses


-research methodology


-env components


- cultural factors


- awareness

Etiology of ASD: Genetics

likelihood of co-occurrence of ASD in:


- ID twins = 36-95%


-fraternal twins = 0-31%


- second child = 2-18%




Occurs more often in the presence of genetic disorders including:


-down syndrome, fragile X, tuberous sclerosis, etc




Occurs more often in older parents

Etiology of ASD: Bio and Env Factors

- advanced parental age


- premature birth, small gestation, and C-Section Birth


- Co-occurs with other dev and psych diagnoses


- maternal infection/immune system


-dairy and wheat


-mmr vaccine




Brain


-epilepsy


-brain volume


-brain structures and connectivity

Etiology of ASD: MMR Vaccine

concern regarding Thimerosal/Mercury




Wakenfield, Murch, Anthony Study (1998)


- 12 children


-gastrointenstinal and other “regressive” symptoms after receiving the MMR vaccine


- concluded that the MMR vaccine may cause autism




Mutch, Anthony, Casson (2004)


- retracted the interpretation that the MMR vaccine may cause autism




Naturalistic study of the incident of autism with and without MMR Vaccine




Autism diagnoses increased from 1993-1996 despite no MMR vaccinations from 1993 on

Treatment for Autism

- early AND intensive intervention


- special education (speech, OT, PT)


- Medication


- Autism- specific interventions





National Standards Project (2015)

5 dimensions of the scientific merit rating scale include:


- exp rigor of research design


- quality of the dependent variable


- evidence of treatment fidelity


- demonstration of participant ascertainment


- generalization data collected

Established Treatments for Autism

- Identified 11 treatment as established effective for those with ASD




- Established treatments are those for which several-well controlled studies have shown the interventions to produce beneficial effects




- There is compelling scientific evidence tons how these treatments are effect however, even among these, universal improvements cannot be expected to occur for all individuals on the spectrum




Types of Therapy


- behavioral


- communication


- social


- education




Established Treatments


- antecedent package (behavioral)


-behavioral package (behavioral)


- comprehensive behavioral treatment for young children (B)


- Joint attention intervention (communication)


-Modeling (behavioral)


- Naturalistic teaching strategies (social?)


-peer training package (social)


-pivotal response treatment (social)


- schedules (education)


-self-management (edu)


- story based intervention package (edu)